Health Care Fraud

Talk to a Criminal Defense Lawyer

It's estimated that as much as 10 percent of all the money spent on
health care every year is paid out on fraudulent claims. Health care
fraud is a crime in which someone uses lies, deceptions, or falsehoods
when filing a health care claim in an effort to make a profit or to gain
some type of benefit. There is no single type of health care fraud, and
health care providers, patients, and even health insurers can commit
this crime. Health care fraud is a crime addressed by both state and
federal laws, and one that has significant potential penalties.

Fraud vs. Mistake

It's
important to distinguish health care fraud from mere mistakes,
omissions, or improper payments. To commit fraud, a person must
knowingly engage in a plan, scheme, or activity to provide falsehoods,
with the intent to achieve some financial gain. Fraud is not the same
as, for example, making a mistake that results in a patient being billed
for treatment he or she did not receive. By contrast, when a health
care provider knowingly provides treatments or procedures that the
provider knows patients do not need, and then bills an insurer for those
procedures in order to make a profit, such conduct is health care
fraud.

Fraud Schemes

Although
anyone involved in the health care process can commit health care
fraud, it is most commonly committed by providers in an attempt to
obtain more money from insurers. Common fraud schemes involve
double-billing or filing duplicate claims for the same service, filing
claims for services never provided, billing for services not covered by
an insurer's policy, and even providing kickbacks for referrals.

Common
fraud schemes perpetrated by patients include faking a medical
condition in order to receive medications that the patient then sells,
falsifying medical claim information, or using someone else's insurance
information to receive health care services.

State and Federal Laws

State laws on healthcare fraud differ considerably. State healthcare fraud laws typically fall into one of three types; false claims laws, self-referral laws, and anti-kickback laws. Some states have laws that address all three types of activity, while others may have only one or two, and some may have none at all.

In
addition to any state prohibitions against health care fraud, federal
health fraud law will apply in most situations. This law is very broad,
applying when anyone makes an attempt to defraud any health care
benefits program with the intent to gain control of money or property.
The federal law applies in all states regardless of whether state law
punishes health care fraud as a crime.

(18 U.S.C. section1347)

Medicare and Medicaid Fraud

The health care system has both private and public health insurers, and healthcare fraud can involve either of them.The two public health care insurers, Medicaid and Medicare, have long been targets of fraudulent claims, and there are a number of federal laws which apply to such situations. Specific federal laws criminalize making false claims in a Medicaid or Medicareclaim (18U.S.C. section 287), making false statements (18U.S.C. section 1001), as well as related activity.

Penalties

Federal
law provides for both civil and criminal penalties for health care
fraud. The difference between a civil penalty and a criminal one is that
criminal penalties allow for fines, prison, and an order to pay
restitution (compensate the victim for any money lost as a result of the
fraud). Civil penalties only result in an order to pay restitution (no
jail time or fine). Criminal health care fraud charges, both at the
state and federal level, can lead to serious consequences for anyone
convicted.

Prison.Health
care fraud is a serious offense, and can lead to lengthy prison
sentences. Making a false claim or false statement in relation to a
Medicaid or Medicare claim can result in a 5 year prison sentence per
offense, while a conviction for federal health care fraud can result in a
10 year sentence for each offense. If the health care fraud results in
serious bodily injury to someone there is a potential sentence of up to
20 years in prison, while an act of health care fraud that results in
someone's death has a potential life sentence.

Fines.Anyone
convicted of health care fraud also faces significant fines. For
example, an individual making a false statement in a Medicaid or
Medicare claim faces a fine of up to $250,000 per offense, while
organizations which make false claims face up to $500,000 per offense.
Organizations that engage in ongoing schemes which involve multiple
counts of health care fraud violations can face millions, or even
billions of dollars in fines.

Restitution.
As part of a criminal fraud sentence, the judge can order defendants to
pay back the amount of money they improperly obtained as a result of
their fraudulent acts. For example, a doctor who improperly billed an
insurance company for tests not performed, and who received payment for
these tests, can be ordered to pay this money back to the insurance
company. Restitution is in addition to a fine, which is paid to the
government.

Probation.An
individual convicted of a health care fraud crime can also face a
potential probation sentence. Probation limits the freedoms a person has
instead of sending the person to serve their sentence in prison.
Probation usually lasts as least 12 months, though sentences of three
years or more are possible. Those on probation must comply with specific
conditions, such as regularly meeting with a probation officer,
maintaining employment, not associating with known felons, and not
committing more crimes.

Speak to an Attorney

Health
care fraud can seem like a minor crime, especially when an individual
commits an act that seems like it has little impact and doesn't really
"hurt anyone." But a conviction for health care fraud, especially when
the defendant is a professional who depends on a license to practice,
can irreparably change the course of that professional's life. Even
being investigated for health care fraud can ruin one's professional
reputation and make life incredibly difficult.

The moment you are
approached by investigators about a potential fraud case, you need to
contact a criminal defense attorney. You can unknowingly incriminate
yourself anytime you speak to an investigator if you don't have legal
advice. Local criminal defense attorneys are the only people capable of
providing you with legal advice in light of their knowledge of the law,
as well as their experience with local prosecutors, courts, and criminal
investigations.

If you're being investigated for breaking a
federal law, your case will be handled in the federal court system. Be
sure that the lawyer you choose has experience handling federal cases.